Case files neurology Flashcards by Josh Spiegel

65 y/o R handed man w/ 20yr h/o tremor w/ posture/intention tremor. similar in mother and daughter. beer reduces tremor
Dx?
Next step?
Management?

Dx: benign essential tremor
Next step: MRI brain and spine
Management: primidone, propranolol

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40y/o in ED for inappropriate behavior/confusion. fidgets for several years w/ choreiform movement. alert but easily distracted. hyperreflexic everywhere
Dx?
Next step?
genetic basis?
Management?

Dx: Huntingtons dz
Next step: review Rx and genetic counseling/testing
genetic basis: CAG expansion of Ch.4 w/ > 40 repeats
Management: Haloperidol for chorea, SSRI for depression, PEG tube for swallowing; goal is to inc. GABA/Ach and dec. dopamine

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21y/o w/ h/o progressive dystonia Left upper extremity to the back or left lower extremity. movement include dystonia, myoclonus, and tremor.
Dx?
Next step?
Management?

Dx: primary generalized dystonia (DYT1)
Next step: MRI brain
Management: deep stimulation of globes pallidus interna; also benadryl/Benztropine

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55y/o w/ asymetric tremor, dec. movement, and rigidity
Dx?
Next step?
Management?

Dx: Parkinsons Dz
Next step: MRI brain for other dx
Management: L-dopa/carbidopa

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Insidious onset of syndrome w/ gait problems
Dx?
Next step?
Management?

Dx: AD spinocerebellar ataxia
Next step: genetic testing
Management: supportive care, rehab

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65y/o w/ h/o GI discomfort, now on metoclopramide, has involuntary mouth/facial movement and arching of back and neck
Dx?
Next step?
Management?

Dx: Tardive dyskinesia
Next step: D/C metoclopramide, start BNZ +/- baclofen
Management: BNZ, baclofen, Vit E

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13y/o obtunded w/ flaccid quadriparesis s/p motor vehicle accident.
Dx?
Next step?
Management?

Dx: High cervical spine injury and traumatic brain injury
Next step: MRI of brain and spine; maintain oxygen and perfusion pressure
Management: give IV steroid if w/in 8 hrs to prevent secondary damage from inflammation

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18y/o athlete w/ acute brain injury from football associated w/ transient loss of consciousness and seizure. after 2 hrs gets N/V/HA
Dx?
Next step?
Management?

Dx: intracerebral bleed –> most likely secondary epidural hematoma
Next step: non-contrast CT
Management: Stabilize and consult neurosurgery

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23y/o F w/ acute AMS 24hrs after trauma w/ brief loss of consciousness. Exam shows attention defects, disorganized thinking and fluctuation of symptoms. PE shows generalized hyperreflexia w/ b/l babinski +
Dx?
Next step?

Dx: delirium secondary to subarachnoid hemorrhage

Next step: CT head, CBC, CMP, UDS

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15y/o boy w/ brief loss of consciousness s/p tackle in football game; mild persistent symptoms > 15 mins after injury
Dx?
Next step?
Management?

Dx: Concussion
Next step: CT w/ contrast
Management: observation w/ reassurance

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68y/o w/ 30 mins of R hemiparesis, aphasia and h/o HTN, CAD, Afib
Dx?
Next step?
Management?

Dx: Acute L MCA ischemic stroke
Next step: Non-contrast CT
Management: thrombolytic therapy if indicated

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50 y/o w/ worst HA of life and neck stiffness, left sided weakness and similar HA 2 wks ago. inc BP and CN3 paralysis. blood shows dec Na and ECG changes
Dx?
Next step?
Management?

Dx: subarachnoid hemorrhage
Next step: non-contrast CT
Management: Cerebral angiography

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22y/o R. horners syndrome and R. hemispheric ischemic stroke s/p minor neck trauma
Dx?
Next step?
Management?

Dx: R carotid artery dissection –> stroke
Next step: cerebral angiogram
Management: surgery

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23y/o lost consciousness and awoke w/ confusion and urinary incontinence
Dx?
Next step?
Management?

Dx: seizure
Next step: BEM (blood labs, EEG, MRI)
Management: NO driving

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23y/o w/ repetitive motor behavior
Dx?
Next step?
Management?

Dx: complex partial seizure
Next step: BEM (blood labs, EEG, MRI)
Management: NO driving

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64y/o w/ acute loss of consciousness w/o warning/provocation or post episodic confusion. 3rd episode of this happening
Dx?
Next step?
Management?

Dx: cardiogenic syncope
Next step: cardiac evaluation and ECG
Management: review meds

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23y/o suddenly seized in all four limbs while conscious complaining about pain and yelling for help
Dx?

Dx: pseudoseizure

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24y/o F w/ 12yr h/o unilarteral headache w/ aura
Dx?
Next step?
Management?

Dx: migraine
Next step: MRI
Management: +/- Rx

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38y/o w/ 10yr h/o daily HA in temples radiating to neck presents different HA 3x in a month over eye w/ N/V. H/o episodic migraine. inc OTC does not help. +occipital pain
Dx?
Next step?
Management?

Dx: chronic daily headache (tension + migraine) w/ analgesic rebound and occipital neuralgia
Next step: neuro exam
Management: tape acetaminophen +/- occipital nerve block

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67y/o w/ h/o 3 yr memory loss recently on amitryptyline x1mo is now extremely confused + agitated
Dx?
Management?

Dx: demential (AD) w/ delirium secondary amitryptyline
Management: ABC, D/C amitriptyline, Rx for dementia

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64y/o w/ progressive decline in personality and auditory/visual sleep hallucinations. +EPS ~ parkinsons
Dx?
Next step?
Management?

Dx: diffuse lewy body dementia
Next step: MRI brain
Management: Rx for dementia

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48y/o w/ progressive gait disorder characterized by sensory ataxia caused by impaired position sense and spasticity. PNS and CNS involvement, including white matter in post cord and pyramidal tracts
Dx?
Next step?
Management?

Dx: subacute combined degeneration of spinal cord (Vit B12 def)
Next step: get Vit B12 labs
Management: give IM B12

23y/o F w/ L subacute painful loss of vision w/o other systemic symptoms. dec. vision in L eye w/ central scotoma. L afferent pupillary defect w/ dec. L extra ocular muscles
Dx?
Next step?
Management?

Dx: optic neuritis
Next step: MRI w/in 2 weeks for optic nerve/other regions
Management: short-course IV methylprednisolone

24y/o w/ multiple neurologic symptoms including blurry vision and realized this has happened before
Dx?
Next step?
Management?

Dx: MS
Next step: Blood studies, LP, MRI
Management: IV steroids —> immune modulating Rx

20y/o w/ multiple neurologic symptoms s/p viral illness 2 wks ago. sudden HA, AMS, CNS dysfxn Dx? Next step? Management?

Dx: ADEM Next step: MRI brain vs. LP (25% develop MS) Management: IV steroids vs. IVIG vs. Plasmapharesis

28y/o w/ 48hr h/o crescendo HA. N/V, and slow response to questions. + kerning sign, nystagmus, and hyperreflexia Dx? Next step? Management?

Dx: Viral Meningitis Next step: CT --> LP Management: IV ceftriaxone, Vanc, Acyclovir, dexamethasone

9mo/o w/ 1 week constipation, poor feeding, weak cry, difficulty sucking/moving arms and legs, hypotension, hypotonia, and hyporeflexia Dx? Next step? Management?

Dx: Infantile botulism Next step: stool/serum culture Management: ICU for respiratory support ---> antitoxin

52 y/o w/ weight loss, forgetful, dec concentration, clumsy, withdrawal from friends. NI MMSE, slow w/ answering questions poor coordination of hands hyperreflexic and HIV+ Dx? Next step?

Dx: HIV associated dementia | Next step: Neuropsychological testing, LP, MRI

53y/o F w/ 4mo h/o rapidly progressive memory loss, ataxia, mood swings, inappropriate behavior, and dysarthria. abnormal MMSE w/ global abnormalities, moderate dysarthria, and anomia. nystagmus, dysmetria, ataxia, myoclonus, hyperreflexia Dx? Next step? Management?

Dx: sporadic CJD Next step: complete serology, LP, MRI, EEG Management: supportive

58y/o w/ h/o syphilis >20 yrs ago has 3 yr h/o leg pain, loss of balance, impotence and ptosis. exam shows argyll robertson pupils, impaired posterior column and lateral spinothalamic tract. hyporeflexic in legs, sensory ataxia, + romberg Dx? Next step? Management?

Dx: Tabes dorsalis Next step: LP for VDRL Management: IV penG 2-4M units q4 x10-14days (doxy/ceftriaxone if allergic)

25y/o s/p tonic-clonic seizure and 6 mo h/o HA has h/o STD/IVRx. CT shows 2x ring enhancing lesions Dx? Next step? Management?

Dx: cerebral toxoplasmosis Next step: Serum IgM + IgG for toxo/ LP PCR Toxo Management: Pyrimethamine, sulfadiaine, folinic acid

17y/o w/ R frontal HA s/p trauma. no LOC, no improvement w/ tylenol. gets better w/ ice. PE shows non reactive R pupil. CT is normal Dx? Next step?

Dx: Holmes-Adie pupil | Next step: apply 0.1% pilocarpine to R pupil

26y/o obese F w/ blurred vision + HA had 2-3 wk transient graying of vision. CT nl , b/l papilledema Dx? Next step? Management?

Dx: inc ICP, likely pseudo tumor cerebri Next step: LP + Optho eval Management: If PTC --> high volume LP

65y/o w/ HTN, CAD, and 24hr h/o binocular horizontal diplopia w./ R lateral rectus palsy Dx?

Dx: ischemic mononeuropathy of CNVI

68y/o w/ R facial paralysis, R ear pain and R sided sensorineural hearing loss. Blisters on erythematous base in R concha, no damage tyrannic membrane Dx? Next step? Management?

Dx: herpes zoster oticus (ramsay hunt syndrome) Next step: tzanck smear, audiogram, CNVII studies Management: anti-viral Rx

30 y/o w/ 2 mo h/o fatigue and ptosis. ptosis improves w/ putting ice water on the eye Dx? Next step? Management?

Dx: Myasthenia gravis w/ ptosis Next step: anti-ACh receptor Ab Management: pyridostigmine (symptoms) + plasmapharesis

63 y/o with episodic positional vertigo w/o hearing loss Dx? Next step? Management?

Dx: BPPV Next step: Dix hall pike Management: epley maneuver +/- symptomatic

64y/o w/ HTN has slowly progressive weakness and stocking glove pattern sensory loss >2mo. normal glucose Dx? Next step? Management?

Dx: CIDP Next step: EMG/NCS Management: Steroids IVIG

25y/o w/ h/o gastroenteritis 5 wks ago presents w/ rapid ascending weakness involving diaphragm. PE shows areflexia, paralysis of legs w/ sensory dz, weakness in arm and swallowing difficulty Dx? Next step? Management?

Dx: AIDP (GBS) Next step: LP for albuminocytologic dissociation Management: FVC --> intubation

30y/o F w/ proximal muscle weakness, skin rash, raynauds, dysphagia, SOB, and arrythmia Dx? Next step? Management?

Dx: Dermatomyositis Next step: skeletal muscle biopsy Management: immunomodulatory Rx/Cardio-respiratory stabilization

64y/o w/ progressive skeletal muscle weakness of BUE/BLE. PE shows pure motor weakness (no sensory loss) + atrophy Dx? Next step? Management?

Dx: ALS Next step: EMG/NCS Management: immediate repiratory/swollow fxn

45y/o RH secretary w/ hypothyroidism has CT syndrome causing her to wake from sleep + Tinel sign Dx? Next step? Management?

Dx: R median nerve neuropathy (Carpal tunnel) Next step: EMG/NCS Management: Splint + analgesic, rehab, surgery

R foot drop in young woman; inability to raise R foot above gravity/ evert laterally Dx? Next step? Management?

Dx: common perineal nerve palsy Next step: EMG/NCS Management: ankle/foot orthotics, surgery

8y/o w/ nocturnal facial twitching. h/o similar nocturnal event 4 yr ago and febrile seizures @1yr/o father had childhood seizures Dx? Next step?

Dx: pediatric seizure disorder w/ h/o febrile sezures | Next step: BEM (blood labs, EEG, MRI)

22mo/o w/ 1 day URI has generalized seizure Dx? Next step? Management?

Dx: simple febrile seizure Next step: determine source (CBC, nasal, LP, UA, CXR) Management: antipyretics + tx source of fever

13 y/o w/ h/o HA has severe HA w/ N/V associated w/ brief prodrome. associated w/ menses Dx? Next step? Management?

Dx: pediatric migraine w/o aura (common migraine) Next step: no diagnostic studies Management: Nsaid +/- triptan for prophylaxis

3y/o w/ proximal muscle weakness, toe walking, calf enlargement. inc CK Dx? Next step? Management?

Dx: douchenes muscular dystrophy Next step: Muscle biopsy +/- peripheral nerve DMD gene Management: supportive, monitor heart and lungs

8 y/o w/ 12 mo h/o motor/phonic tics and concurrent OCD Dx? Next step? Management?

Dx: tourrettes Next step: clinical dx Management: education and Rx if needed

7 y/o w/ nocturnal spell of hemifacial clonus and speech arrest --> secondary tonic clonic. post octal confusion, + FHx Dx? Next step? Management?

Dx: Benign rolandic epilepsy Next step: outpatient EEG Management: reassurance as will resolve

13y/o w/ recurrent seizures, mental retardation, delay. Birth h/o IUGR, cryptochidism, craniofacial dysmorphism, sacral dimple Dx? Next step? Management?

Dx: miller-dieker syndrome ~ lissencephaly type1 Next step: MRI brain Management: symptomatic Rx

2 y/o w/ delayed language, abnormal social interaction and abnormal behavior w/ no other problems Dx? Next step? Management?

Dx: autism Next step: audiological evaluation Management: education + behavior modification

43 y/o w/ h/o HA hearing loss and facial paralysis Dx? Next step? Management?

Dx: cerebellopontine angle mass (MC acoustic neuroma/meningioma) Next step: MRI w/ gadolinium Management: surgery/observation

60y/o w/ 20 pack yr smoking hx has 6 wk R frontal temporal HA. + personality change, dec left arm swing, L finger extensor and + L babinski Dx? Next step? Management?

Dx: Metastatic brain tumor (lung) in R cerebral hemisphere Next step: MRI w/ and w/o gadolinium + CXR Management: corticosteroids/ andticonvulstants

NB w/ hypotonia, frog leg, hyporeflexic and fibrillations Dx? Next step? Management?

Dx: SMA type 1 (werdnig hoffmans dz) Next step: SMN1 gene testing Management: Respiratory support / supportive therapy